Denial Coding Analysis - An overview

Before we talk about what is denial analysis, we should know what claim denial is.

When we send claim to insurance, it goes through adjudication system and get processed. After processing, if claim is considered not payable then it is called denial. Denial can be due to various reasons. -- For example Diagnosis reported is not considered medical necessity for the procedure or procedure reported is not covered by the insurance.

For you to know the reason of denial, Insurance/payer will issue EOB(Explanation of Benefit) or ERA(Electronic Remittance Advice) with denial codes/adjustment codes with prefix of CO, OA, PR or PI.

Coding Denial

As I stated earlier claim denial can be due to various reason that can be due to clerical errors, coverage, payer initiated reduction or any coding error etc.

So any denial due to coding error can be termed as coding denial. Generally coding denials are worked by coders after receiving from accounts receivable (AR) department. A denial coder should have basic knowledge on denial reason codes to work towards solution accurately. Below are few common coding related denial reason codes.

CO-4: The procedure code is inconsistent with the modifier used. For example you have given

CO-6: The procedure code is inconsistent with the patient's age.

CO-7: The procedure code is inconsistent with the patient's gender.

CO-9: The diagnosis is inconsistent with the patient's age.

CO-10: The diagnosis is inconsistent with the patient's gender.

CO-11: The diagnosis is inconsistent with the procedure.

CO-49: This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam.

CO-50: These are non-covered services because this is not deemed a 'medical necessity' by the payer.

CO-146: Diagnosis was invalid for the date(s) of service reported.

CO-181: Procedure code was invalid on the date of service.

When we talk about coding denial, do not assume that always there is an error in coding, but it can be due to clerical mistakes in your practice management system or there may be error with insurance. So you need to think different angles to find proper reason of denial.

For Example – You have received denial as patient age is inconsistent with procedure with CO-6 as denial code.

To work on above denial you should follow below steps...

• Check coded procedure (CPT) description

• Match with patient age in your demographic data

• Verify registered demographics with insurance (if you have access)

• If patient DOB is correct in your PMS and with insurance then change your procedure coding and send back to concerned team

• If you found DOB mismatch in your PMS and with Insurance then forward to concerned team for further action (to contact insurance or patient for the update)

As you see example above, I am giving steps and points of different aspects below to deal denials appropriately.

Remember actions mentioned are to be taken as per your denial analysis. It would be better if a coder capable of good communication could work in AR dept. to minimize coding denial turnaround time.